This form needs to be postal mail or emailed with a deposit by check, PayPal or credit card to confirm your spot in the session at least 10 days prior to the beginning of the series you wish to partake in.

Copy and paste this into a word document to fill out,

or it can be sent to you via email for download. 

Enrollment Form

                                                                                                                                                                                                      Today’s Date____/____/15

 

Mother:                                                                                                                                     Age:                Maiden Name:                                                             EDD:         /       /15    # weeks pregnant             Home Phone:                                                         Cell Phone:                                                                   Email:                                                                                                                                                                Address:                                                                             City/State/Zip:                                                      Occupation:                                                                                Work Phone:                                              Educational Level/Degrees:                                                                                                                         Birth Partner’s Name:                                                                                                              Age:                Relationship to Mother:                                                         Occupation:                                                  Cell Phone:                                                                          Work Phone:                                                          Email:                                                                                                                                                                Baby/Babies Order of Birth:            Gender(s):             Nickname(s):                                                       If not your first child, please list names and ages of siblings on back of this sheet >>>>>>>>>>>>> Obstetrician or Midwife Information:

Name:                                                                                                 Phone:                                                Address:                                                                                      City/State/Zip:                                             Email:                                                                                                                                                                Birthing Location:

Name:                                                                                         Phone:                                             Address:                                                                               City/State/Zip:                                         Website:                                                                                                                                              Do you have any previous experience with hypnosis? Y N

If so, please describe on back of this sheet >>>>>>>>>>>>>

 

Previous or current childbirth preparation classes?

 

Type:                                                                               Location:                                                     How did you hear about HypnoBirthing?                                                                                           What are your 3 most pressing concerns regarding your birthing experience?

1                                                                                                                                                                          

 

 

 

2                                                                                                                                                                          

 

 

 

3                                                                                                                                                                          

 

Please state the dates and location that you are interested in:

                                                                                                                                                                         

Thank you!

Once you have completed the above form and have signed the Client Bill of Rights and the Agreement Form [make sure to have it witnessed by a non-related person], please make copies for yourself.

Mail all 3 originals with a $97 deposit to: OBAAT 84 Victor Street, Plainview, NY 11803 ATT: Debi Tracy Please make the check out to: Debi Tracy. You can also scan and email forms then send deposit/full payment by PayPal. All deposits are non-refundable however exchangeable for [1] private session if enrollment is cancelled prior to first class by emailed or verbal confirmation.

Bring your insurance form the first night so I may sign it. Balance is due in full at your first session by check, in cash, credit card or PayPal unless other arrangements have been made prior. No refunds after first class. A $15 processing fee will be incurred if balances paid are by PayPal or credit card. A $25 media fee will be incurred if media materials are not returned by last day of class.

PLEASE NOTE:

For 2015, private hypnosis session fees are $97 initial visit, $77 per follow up session.

—————————————————————————————————————————————

Office use only: SERIES

Group {3>}:   $97 per class       [5 classes; no travel fee; 10% off if PIF with enrollment form]

Private {1}: $977 per series       Semi-Private {2}:   $677 per couple

if in-home and less than 15 miles one way there is no travel fee for semi-privates or privates

Insurance Form

 

 

Patient’s Last Name:                                                           First:                                             Initial:     DOB:     /   /       Relationship to Subscriber:                                                                                   Address:                                                             City:                                     State:           Zip:

Phone:                                                                         Subscriber:                                                                      Referring Physician/CNM:                                                                                  Due Date:                              Insurance Carrier:                                                                                 Ins.ID #:                                               Coverage Code:                                                                             Group:                                                        RELEASE: I authorize the undersigned health care provider to release any information acquired in the course of my examination or treatment.

 

SIGNED:                                                                                                             Date:           /           /2015 (Insured or Authorized Person)

 

 

 

Description                                                   CPT Code                              Fee

Childbirth Education Classes: Group           99078

Childbirth Education Classes: Private          99342

Educational Supplies (CDs, DVDs                99071

etc. provided for the client’s education

at cost to the educator)                                                          Total Fees:

Amount Paid:

 

Balance Due:

 

 

 

 

Provider’s Signature                                                                                                                              

Debi Tracy, Certified Childbirth Educator

 

 

 

Dates of Service                                                                                                           /2015

 

Instructions to client for filing insurance claims:

 

Complete your insurance carrier’s claim form and submit directly to your insurance with this form.

Enrollment Agreement

 

 

 

We,                                                                  and                                                               , hereby state that WE are enrolling in the HypnoBirthing® class of our own free will and with the understanding that this program is designed to teach us to use our own natural abilities to bring my mind and body into a state of relaxation. WE further understand that the content of these classes is in no way intended to be represented neither as medical advice nor as a prescription for medical procedure. WE are aware that WE should seek the advice of a medical doctor and/or a certified nurse midwife to answer any health-related or pregnancy-related issues surrounding our pregnancy, our labor and/or our birth.

 

 

WE, therefore, agree that WE will in no way hold Debi Tracy, or One Birth At A Time, or The HypnoBirthing® Institute, or it’s owners, or it’s representatives, responsible for any complications that could arise as a result of our pregnancy, our labor, or the delivery of our child or children; and WE agree that neither WE nor any member of our family will make any claim or initiate any suit against

any of the above-named parties now or at any time in the future.

 

 

 

 

 

Mother [PRINT]                                                                                 Non-Related Witness [PRINT]

 

 

 

 

Signature of Client                                                                          Signature of Non-Related Witness

 

 

 

 

                                                           /2015

                                       /2015

 

Date                                                                                                   Date

 

 

 

 

Birthing Partner [PRINT]

 

 

 

 

Signature of Client

 

                                                /2015

Date

 

Client Bill of Rights

 

Contact Information: My name is Debi Tracy. I can be contacted at this address: 84 Victor Street, Plainview, NY 11803 or by telephone at 516.351.7792.

 

Related Education and Training: I received my National Guild of Hypnotist’s Certification in Clinical Hypnotism in 2005, my Certification in HypnoBirthing® Fertility Therapy at Eastburn Institute of Hypnosis in Colorado in

2005 and my Certification in HypnoBirthing® Childbirth Education from The HypnoBirthing® Institute in 2001. I

also receive annual continuing education to maintain my training at a high level.

 

Notice:   “THE STATE OF NEW YORK HAS NOT ADOPTED ANY EDUCATIONAL AND TRAINING STANDARDS FOR THE PRACTICE OF HYPNOTISM. THIS STATEMENT OF CREDENTIALS IS FOR INFORMATIONAL PURPOSES ONLY. Under New York State law a hypnotist may not provide a medical diagnosis or recommend discontinuance of medically prescribed treatments. The services I render are held out to the public as nontherapeutic hypnotism, defined as the use of hypnosis to inculcate positive thinking and the capacity for self-hypnosis. I do not represent my services as any form of medical, behavioral or mental health care, and despite research to the contrary, by law I may make no health benefit claims for my services. If a client desires a diagnosis or any other type of treatment from a different practitioner, the client may seek such services at any time. In the event a client terminates my services, the client has a right to coordinated transfer of services to another practitioner. A client has a right to refuse hypnosis services at any time. A client has a right to be free of physical, verbal or sexual abuse. A client has a right to know the expected duration of treatment, and may assert any right without retaliation.”

 

Redress: I am a certified member of the National Guild of Hypnotists, and practice in accordance with its Code of Ethics and Standards. If you have a complaint about my services or behavior that I cannot resolve for you personally, you may contact the National Guild of Hypnotists at P.O. Box 308, Merrimack, NH 03054-0308, (603) 429-9438, to seek redress. Other services than my own may be available in the community. You may locate such providers in the telephone book or on the Internet.

 

Fees: The charges for my services are as discussed. You will be given 30 days notice of any change in fees. You may pay for services by check, credit card, cash or PayPal.   Charges and PayPal payments incurs additional processing fees.

 

Confidentiality: I will not release any information to anyone without a written authorization from you, except as provided for by law.

 

Insurance: In general, insurance companies do not cover hypnotic services, and I caution you not to expect them to do so.

 

My Approach:   Assisting you in achieving your goal(s) through the utilization of hypnotherapy, relaxation training, visualization, imagery and fear release techniques.

 

Your signature(s) indicates that you have read and understand this Client Bill of Rights:

 

 

 

Signature:                                                                                                               Date       /       /15

 

 

 

Name {PRINT}:                                                                                                            

 

 

 

Signature:                                                                                                                          Date         /         /15

 

HypnoBirthing® Institute                                                                                                        

PO Box 810, Epsom, NH 03234 – (603) 798-3286

 

 

 

 

 

 

 

Permission to Use Images

 

 

 

 

Subject: HypnoBirthing® birth educational video/images

 

 

 

 

I grant to Marie F. Mongan and/or The HypnoBirthing® Institute, its representatives and employees the right to use images of me/us/our baby in connection with the above-identified subject. I authorize the HypnoBirthing® Institute, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

 

I agree that Marie F. Mongan and/or The HypnoBirthing® Institute may use such images of me/us/our baby with or without my name and for educational and promotional purposes.

 

I have read and understand the above:

 

Signature:

                                                                                                                                  Date         /         /15

 

 

 

Name {PRINT}:                                                                                                                       

 

 

 

Signature:

                                                                                                                                  Date         /         /15

 

 

 

Name {PRINT}:                                                                                                                       

 

 

 

 

Organization Name (if applicable)                                                                                                                   

 

Address                                                                                                                      

 

Signature, Parent or Guardian                                                                                (if under age 18)

 

Name {PRINT}:                                                                                                         

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